the gall bladder and gallstones

the liver, gall bladder, bile duct and bile
gall stones and their complications
causes of gall stone formation
symptoms and diagnosis
nonoperative treatment, and asymptomatic stones
surgical treatment
diet
drugs used in this condition
when to consult your doctor
further reading


the liver, gall bladder, bile duct and bile

The gall bladder is a bile- filled organ situated in the right upper abdomen, on the undersurface of the liver. The substances dissolved in it often precipitate to form masses which we call gallstones. Since gallstone disease is so common, it is important for every person to be aware of its significance.

The liver is situated in the right upper abdomen, and performs several major tasks. It makes protein, fat and carbohydrate. It also produces bile.

The bile is a fluid produced in the liver, and contains waste products of metabolism. Bile also helps in digestion, in particular the absorption of fat. The bile flows from the liver cells to the intestines via a tube called the bile duct. The gall bladder is a sac attached to the side of the bile duct. It stores the bile, and releases it into the intestine when food is eaten, to help in digestion.

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gall stones and their complications     

Bile contains cholesterol, lecithin, and various complex organic compounds*. The concentration of cholesterol and the other compounds is present in a delicate balance. If this balance is disturbed the compounds can precipitate quite easily. The precipitated solvents form masses called "stones" or gall stones. Gall stones vary in size from small grains, called "biliary sludge" to large, hard masses 3 or more centimeters across. Most stones are made of cholesterol, some are made of the organic bile compounds.

*eg the bile salts, sodium and potassium taurocholate, and the bile pigments, bilirubin and biliverdin.

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causes of gall stone formation

Gall stones are more commonly seen in females, and tend to be slightly commoner in fat ladies who have had many children. The intake of estrogens (as in contraceptive pills) has been linked to the development of gall stones. Patients who have had typhoid are more likely to form stones. Certain blood diseases, and some forms of intestinal operations predispose to the formation of gall stones. Any gall bladder disease, including cancer, can in fact result in gall stone formation.

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symptoms and diagnosis

Gallstones are much more common among females than males. Stones irritate the gall bladder, which swells and thickens, and develops an inflammation. The patient feels pain in the upper abdomen, usually on the right and less often in the midline. Indigestion may occur, with fullness after meals, a feeling of gas, abdominal heaviness and other features. Mild and recurrent disease is called chronic cholecystitis. The disease may be more severe, as in acute cholecystitis and in gall bladder empyema. Patients with more severe attacks of cholecystitis have marked pain, and sometimes have fever.

In the past it was very difficult to diagnose gallstones. However since the availability of ultrasonography the diagnosis of gallstones and cholecystitis has become very easy. The gall bladder is clearly seen as a bag of fluid. Stones show up easily, and also block ultrasound rays, throwing a sort of shadow in the ultrasound picture. The accuracy of ultrasonography is over 98%. The radiologist will make a diagnosis of gallstones (also termed "cholelithiasis") along with cholecystitis.
Blood tests to evaluate the liver function are usually done as well. A very few other investigations are needed to evaluate fitness for operation.

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nonoperative treatment, and asymptomatic stones

There is no effective medical, nonoperative therapy for gall stones. Some drugs have been used, but have too many side effects to be recommended as first-line therapy. For those who absolutely refuse surgery, ayurvedic and homeopathic treatments may be considered.

A large number of healthy persons have gall stones, which are often detected during ultrasonography for some other indication (eg during pregnancy). 33-66% of asymptomatic persons with gallstones will develop symptoms sometime in life. Presently it is controversial if all people, in whom gallstones are detected, should undergo operation. Overall the balance of medical opinion is that if there are asymptomatic gallstones, they should be left alone. However, keeping in mind the many complications of gallstones, all surgeons recommend that even a single episode of pain is an indication for surgery. When dyspepsia is the main symptom, it is perhaps better to advise gall bladder surgery only after peptic ulcer has been thoroughly ruled out.

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surgical treatment

Gall bladder surgery. Treatment of gallstones is by removal of the gall bladder, in an operation called a cholecystectomy.
Surgery should be done not as an emergency, but at the patient's earliest convenience. In the absence of complications one may wait for an important family event to be concluded, but otherwise it is inadvisable to delay surgery for too long.
The usual method of removal of the gall bladder is by a
laparoscope. In a laparoscopic cholecystectomy 4 holes ("ports") are made in the abdomen. The laparoscope is inserted through a hole near the umbilicus, and the other holes are for the operating instruments. The operation takes roughly an hour, and the patient can ordinarily be sent home in a day. Most persons are back to work within a week or so. Complications after surgery are few. Infection at the site of one of the ports may occur rarely. Some patients develop a hernia which will need a small operation for correction. A rare but serious complication is an operative bile duct injuries.
Cholecystectomy by making a large abdominal incision ("open surgery") is less often performed nowadays. The gall bladder is removed through a 10-12 cm incision in the upper abdomen. Although open operation is slightly safer, the pain and time off work are significantly more than those seen after laparoscopic surgery. In the open operation, wound infection and hernias are also commoner, but bile duct injuries are rarer. At 5-6 weeks after surgery, there is no difference between patients who have undergone the different types of operation, therefore if laparoscopic surgery is proving difficult, the surgeon should have no hesitation in converting to the open type. Safety first!

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diet

Patients with gall stones may take any type of diet, before or after surgery. Some patients do not tolerate certain types of meal, for example heavy meals or meals containing too much fat. If these cannot be tolerated the patient will naturally have to adjust the diet accordingly.

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drugs used in this condition

Painkillers: diclofenac,dextropropoxyphene, tramadol, pentazocine, pethidine, and antispasmodics such as dicyclomine
Antibiotics: during the phase of acute cholecystitis, these may be needed
Ursodeoxycholic acid and chenodeoxycholic acid: drugs used for dissolution of gall stones, without surgery. Not recommended as primary treatment because of their low efficacy and high incidence of side effects.

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when to consult your doctor

Severe pain in the abdomen is always in indication for visiting your doctor. Patients in whom gall stones have been detected should see their doctor to arrange early surgery.

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Further reading

http://www.niddk.nih.gov/health/digest/pubs/gallstns/gallstns.htm: very informative
http://surgery.about.com/health/surgery/msubfaq.htm: a good site to visit, has many topics including gallstones
http://www.surgeries.com/gallblad.shtml: a good gallbladder site
http://www.ppphealthcare.co.uk/html/health/cholec.htm: fairly informative on cholecystitis
http://www.thrive.net/health/Library/pedillsymp/pedillsymp81.html: worth seeing

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Author

Dr Suneet Sood, MBBS (AIIMS), MS (AIIMS), MAMS, is a practising surgeon attached to Dharamshila Cancer Hospital, Sir Ganga Ram Hospital and to Noida Medicare Center. Formerly Professor of Surgery, Himalayan Institute of Medical Sciences, Dehradun, Dr Sood has a special interest in gastrointestinal surgery. He has had an active academic career, has published several papers in national and international journals, and is the Editor (with Dr Anurag Krishna) of a widely acclaimed book titled Surgical Diseases in Tropical Countries.
Contact Nos: 2486788, 9811052966, suneetsood@vsnl.com


Editorial board:

Dr Suneet Sood,MS, MAMS, Editor in chief
Dr Anurag Krishna, MS, MCh, MAMS


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Last revised: May 11, 2000